Impact of evidence‐based nursing on surgical site wound infection after caesarean: A meta‐analysis

Abstract We conducted this study to investigate the effect of evidence‐based care on surgical site wound infection after caesarean section. A computerised search of PubMed, Embase, Google Scholar, Cochrane Library, China National Knowledge Infrastructure and Wanfang databases for randomised controlled trials (RCTs) on the use of evidence‐based care in caesarean section delivery was applied from the database inception to November 2023. Two researchers independently screened the literature, extracted data and performed quality assessment based on inclusion and exclusion criteria. Stata 17.0 software was applied for data analysis. Twenty‐one RCTs involving 3269 caesarean sections were finally included. The analysis revealed the implementation of evidence‐based nursing interventions was effective in reducing the incidence of post‐caesarean section wound infections (OR = 0.29, 95% CI: 0.21–0.39, p < 0.001) and complications (OR = 0.29, 95% CI: 0.23–0.38, p < 0.001) compared with conventional care. This study shows that the application of evidence‐based nursing in postoperative caesarean section care can effectively reduce the incidence of postoperative wound infection and complications and improve the quality of life, which is worthy of clinical nursing application and promotion.


| INTRODUCTION
Caesarean section is an important modality for the treatment of contaminated amniotic fluid, macrosomia, malposition, premature rupture of membranes and pelvic dysplasia, as well as for obstetric critical care, and it is one of the most commonly performed surgical procedures. 1,24][5] Wound infections range from mild superficial incision infections to severe endometritis, pelvic abscess and sepsis. 6Currently, the global incidence of post-caesarean section wound infections ranges from 3% to 15%. 7Failure to control wound infections effectively may lead to an increase in serious complications and mortality rates. 8,9Wound infections and complications after caesarean section seriously affect the postoperative recovery of mothers, so it is important to strengthen the postoperative nursing interventions for caesarean section mothers to improve their prognosis.
Conventional care is effective in promoting patients' postoperative recovery, but usually fails to integrate with patients' wishes and lacks spiritual and psychological care. 10Evidence-based nursing is based on nursing problems in clinical practice, analysing a large amount of clinical information and summarising it with their own experience, improving the personal skills and clinical experience of nursing staff and laying a solid foundation for the development of personalised nursing programmes by nursing staff. 11,124][15][16] Therefore, we conducted this study aimed to evaluate the effect of evidencebased nursing on post-caesarean section wound infection, and to provide an objective evidence-based medical basis for future clinical nursing work.

| Literature search
Using caesarean, caesarean section, evidence-based nursing, EBN, evidence-based nursing practice and evidencebased practice as keywords, a combination of subject terms and free words were used to search the PubMed, Embase, Google Scholar, Cochrane Library, China National Knowledge Infrastructure and Wanfang databases for randomised controlled trials (RCTs) on the use of evidence-based care in caesarean section delivery was applied from the database inception to November 2023.

| Inclusion criteria
(1) Participants: caesarean section mothers; (2) intervention: evidence-based nursing intervention in the experimental group and conventional nursing in the control group; (3) outcomes: wound infections, complications and (4) study design: RCTs.

| Exclusion criteria
Duplicate publications; literature that lacks relevant raw data, has incomplete raw data, or for which full-text data information is not available; reviews, case reports, systematic evaluations, conference articles and animal studies.

| Data extraction and quality assessment
The retrieved literature was imported into Endnote X9 literature management software to remove duplicates, followed by screening by two researchers who independently read the titles, abstracts and full text to decide whether to include the literature based on the inclusion and exclusion criteria, and if there was a disagreement between the two researchers during the screening process, the issue was resolved through a joint discussion or with the assistance of a third researcher.Excel software was used for data extraction, including first author, year of publication, sample size, sex and age and outcome indicators (wound infection, complications).RCTs were quality assessed using the risk of bias tool recommended by the Cochrane Collaboration, which assesses the risk of bias in six main areas: selection bias, implementation bias, measurement bias, follow-up bias, reporting bias and other biases.

| Statistical analyses
Stata 17.0 software was applied for data analysis.Dichotomous variables were expressed as odds ratios (ORs) and their 95% confidence intervals (CIs).Heterogeneity was determined using the χ 2 test and the I 2 value; when I 2 < 50% and p > 0.1, it indicated no significant heterogeneity and a fixed-effects model was applied; otherwise, a random-effects model was applied.The robustness of the findings was assessed by sensitivity analysis.When the number of included literature exceeded 10, publication bias was assessed using funnel plots.

| Basic characteristics of the included studies
The literature screening process is shown in Figure 1.A total of 335 documents were retrieved at the beginning of the study, 159 duplicates were removed manually and by software, 96 documents that were inconsistent with the study were removed by reading the titles and abstracts of the documents according to the screening criteria, and the remaining 80 documents were read in full text, and 21 RCTs were finally included,  totalling 3269 cases of caesarean section, including 1645 cases in the evidence-based nursing group and 1624 cases in the conventional nursing group. The bsic characteristics of the included literature are shown in Table 1.Literature risk assessment is shown in Figure 2.

| Wound infection
Wound infections were reported in 21 RCTs.There were 1645 cases in the evidence-based nursing group, of which 53 had wound infections, and 1624 cases in the conventional nursing group, of which 165 had wound infections.No significant heterogeneity was found (I 2 = 0.0%, p = 0.915), and a fixed-effects model was applied.The analysis revealed, in terms of wound infection, the incidence of the evidence-based nursing group was significantly lower than that of the conventional nursing group (OR = 0.29, 95% CI: 0.21-0.39,p < 0.001) (Figure 3).

| Complication
Fourteen RCTs reported the occurrence of complications.There were 1225 cases in the evidence-based nursing group, of which 101 had complications, and 1204 cases in the conventional nursing group, of which 275 had complications.No significant heterogeneity was found (I 2 = 41.3%, p = 0.053), and a fixed-effects model was applied.The analysis revealed, in terms of complications, the incidence of the evidence-based nursing group was significantly lower than that of the conventional nursing group (OR = 0.29, 95% CI: 0.23-0.38,p < 0.001) (Figure 4).

| Sensitivity analyses and publication bias
Sensitivity analyses by excluding single studies one by one showed that the findings of this study were robust The forest plot of postoperative complications.
(Figure 5).The results of the plotted funnel plot are shown in Figure 6, which is largely symmetrical on both sides of the funnel plot, suggesting a low likelihood of publication bias.

| DISCUSSION
Clinical caesarean section is a means of managing abnormal and high-risk pregnancies, and can effectively resolve difficult deliveries due to abnormalities of the placenta and umbilical cord, cephalopelvic asymmetry, and obstruction of the soft birth canal. 38,39With the rapid development and progress of society and medicine, the rate of caesarean section has increased significantly. 40aesarean section, as an invasive means, also has a series of complication risks, is highly traumatic to the mother, and is prone to various adverse reactions, causing physical and mental damage to the mother and lowering the quality of her life. 41Therefore, active nursing intervention after caesarean section is of great significance.However, the traditional nursing model can no longer meet the actual needs of patients, evidence-based nursing is a novel modern clinical nursing model, the core is 'patientcentred', through the changes in the patient's condition, combined with the clinical practice experience and scientific and safety evidence-based nursing practice basis, to meet the patient's needs for diversified nursing services, and thus achieve more satisfactory nursing results. 42ound infection is one of the most common complications 43 that affects women in labour, and in severe cases can be septic and even life-threatening. 44,45Our results showed that the incidence of wound infection and complications in the experimental group was significantly reduced after evidence-based nursing intervention, which is a significant improvement compared with the control group.Because evidence-based nursing is a new clinical nursing model developed gradually from the concept of evidence-based medicine into the clinic, with the help of evidence-based medical assessment methods, through the research of clinical nursing process to summarise the evidence-based problems; and then collect relevant literature in various databases, study, learn from advanced nursing methods, combined with the existing healthcare environment and resources, to improve the nursing programme to make it more accurate, scientific and more feasible and effective; and then finally, improve the nursing programme to make it more accurate, scientific and more feasible and effective.Finally, by referring to the mother's wishes and clinical experience, a personalised care plan that meets the mother's needs is formulated, which improves its relevance and purpose and has a more ideal clinical application effect, thus it can effectively reduce the incidence of wound infections and other complications after caesarean section. 46,47n conclusion, the application of evidence-based nursing in postoperative caesarean section care can effectively reduce the occurrence of postoperative wound infections and complications, improve the quality of life of patients, and benefit both patients and caregivers, which is worthy of being promoted for use in the clinic.However, there are still some limitations in this study; the literature included in this study is relatively small; only published Chinese literature was included; there may be a certain language bias, which affects the credibility of the results of the study; and I hope that in future, there can be more high-quality clinical studies with rigorous scientific design to reduce these limitations.

6
The funnel plot of publication bias.(A) Wound infection.(B) Postoperative complications.
The risk of bias graph of the included studies.